Healthcare Provider Details

I. General information

NPI: 1831189117
Provider Name (Legal Business Name): REBECCA LYNN BENNETT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 03/25/2024
Certification Date: 03/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49725 COUNTY 83
STAPLES MN
56479-5280
US

IV. Provider business mailing address

49725 COUNTY 83
STAPLES MN
56479-5280
US

V. Phone/Fax

Practice location:
  • Phone: 218-894-1515
  • Fax: 218-894-8767
Mailing address:
  • Phone: 218-894-1515
  • Fax: 218-894-8767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9463
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: